Identifying the elements of human finitude tells only part of the story about the human context of the Patient Self-Determination Act. These features can be generalized to all human beings and may be considered to be abstract and somewhat distant from the particular situation in which individual patients find themselves. But there is another dimension to being a patient and, therefore, the human context of healthcare, which must be taken into account in the clinical situation and is an intimate component of the patient's personal situation. This is the notion of dignity and its importance in one's life.⁽¹⁾ This notion is multifaceted and constructed of a variety of elements which cannot be ignored if patients are to flourish.

    Virtually all codes of ethics which address the care of patients in the clinical setting declare that the dignity of patients must be respected, affirmed, supported, or promoted.⁽²⁾ However, these codes fail to specify exactly what patient "dignity" means. Furthermore, few offer detailed instructions on how this dignity is to be nurtured in the clinical setting other than by seeking the "well-being" of patients through a series of specific actions. The presumption seems to be that "respecting dignity" would mean the same thing for each patient. When ethical directives are given, the direct relationship between the directive and patient dignity is seldom articulated. The Patient Self-Determination Act offers us the opportunity to reflect upon the meaning of patient dignity and the many ways in which the spirit of the law can contribute to fostering it.⁽³⁾

    The word "dignity" comes from the Latin "dignus" meaning "worthy." Thus, to have dignity means that one has worth or value. But it carries the connotation of having value of a special sort. When one has dignity one has worth or value which flows from an inner source. It is not given from the outside but rather is intrinsic to the bearer of dignity. Thus, a painting may have value but it does not have dignity. The value is placed upon it by the members of the artistic community in light of the skill of the artist and the aesthetic priorities of the community. The value does not derive from the painting itself. Persons, on the other hand, can be said to possess dignity as an inner source of worth. If this were not the case they would simply be the bearers of instrumental value like all other objects in the world. Instead human beings are set apart and treated in special ways.⁽⁴⁾

    There is a variety of ways which may account for the derivation of the dignity which individuals enjoy. These accounts will vary depending upon one's belief system, either theological or philosophical. One of the most obvious ways of talking about the source of dignity is to think about it in terms of a creator-creature relationship.⁽⁵⁾ On this view individuals have dignity because they have been created by a divine source which imparts dignity to them as a fundamental constituent of their make-up. This derivation from the divine gives a special significance to the dignity of individuals. It generally carries with it the notion of a providential concern for individuals and a special protection which is given to them which is accorded to no other creature.⁽⁶⁾ For this reason, an affront to the dignity of individuals within this context is also an affront to the divine source. Consequently, special penalties are attached to these transgressions.

    Another, and more naturalistic, approach to the derivation of human dignity is the anthropocentric belief that human beings occupy a special place in nature.⁽⁷⁾ This belief holds that, in the evolutionary process, human beings have developed a range of intellectual abilities which allows them to lay claim to a superiority among all other species. Human beings are seen as possessing capabilities of such magnitude that they can dominate other species and direct the course of even natural processes to a great extent. This vantage point of control and privilege confers on human beings the dignity and special respect which they enjoy.

    An existential approach to human dignity would hold that individuals possess dignity in virtue of their ability to choose.⁽⁸⁾ On this view we are the only manifestation of life which can determine itself. All others are totally bound by the exigencies and limitations of nature. Human beings, on the other hand, are undetermined, in major ways, by outside forces. Rather, the assertion is that we make ourselves to be who we are by the choices which we make in our daily lives. As self-makers,⁽⁹⁾ we are more powerful than other species and can lay claim to a special regard from others. We are required to respect other persons because their being flows from within them through their choices rather than being imposed upon them externally.

    Although there may be many other ways of attempting to account for the derivation of human dignity which cannot be explored at this time, one more explanation requires some attention. This view, which is the opposite of the anthropocentric approach, is a view which is an undercurrent of many Eastern religions⁽¹⁰⁾ and Native American belief systems.⁽¹¹⁾ On this view, human dignity depends not on the separation of persons from other species or their superiority vis à vis other species. Rather, personal dignity rests on the integration of individual human beings into the larger community of living things and natural processes. Individuals who behave in an independent or "renegade" fashion have no dignity because they have forsaken the ground upon which their being rests, namely, their participation in a process larger than themselves. On this view "to be" is "to be related" and to have dignity is to consciously enter into this network of relationships.

    Regardless of the derivation which might be considered to be a reasonable and accurate account of human dignity, there is little disagreement that persons are considered to possess it as a moral claim on the behavior of others.⁽¹²⁾ And even if the concept of dignity were to be extended to other living things, human dignity would still remain the foundational model for understanding and laying claim to the notion of intrinsic worth which demands special consideration.

    To understand the various ways of deriving human dignity or to subscribe to a particular account is only a small part of exploring the notion of human dignity. For in spite of its derivation the facets of personal dignity present a similarly complex structure. Just as there are many dimensions of finitude which must be understood if we are to understand fully its impact on our lives, there are many dimensions or facets of personal dignity which must be explored if we are to have a genuine appreciation of it. It is to these many aspects which we will now turn, keeping in mind that to respect one's dignity requires respect for the full network of the facets of one's dignity. To violate one of the facets of dignity is to violate the person's dignity itself. Each individual will emphasize some facets and deemphasize others. Each person will hold tenaciously to some and willingly compromise on others. Each individual will arrange the dimensions in different orders of priority. For all of these reasons each individual is truly unique with a distinctive texture to her dignity. It is virtually impossible to predict how these personal profiles will be shaped. It is for this reason that caregivers must be sensitive to the various features of their patient's dignity and attempt to discover how each patient's dignity is constituted; for there are as many ways to violate a patient's dignity as there are components of that dignity.

   Embodiment is the first facet of personal dignity which ought to be considered explicitly because, in one way, it is the most obvious but, in another way, one of the most neglected. Each individual has a special sense about what it means to be a body and a body of a particular type with particular attributes. Often this translates into "body image." But it also can involve the attachment which we have to our bodies.

    Some individuals are very private about their bodies and require that intrusions into their bodies be kept at an absolute minimum. Such individuals would probably limit surgical interventions and allow them only for the most grave reasons. Some individuals may have developed a view of their bodies as a set of natural processes which have great self-healing powers, not to be polluted by foreign substances such as toxic chemicals which others may classify as "therapeutic medications." Some may have aesthetic perceptions of their bodies and resist alterations even as a last resort. For this reason some women will refuse mastectomies even at great risk to their lives. Some will view their bodies as consecrated temples and limit certain kinds of intrusions such as Jehovah's Witnesses' refusing blood products. Finally some individuals may achieve some detachment from their bodies, particularly in the process of dying, and willingly surrender themselves to its deterioration.

    There is legitimacy in each of these approaches to embodiment and one cannot respect a patient's dignity unless she understands where the patient stands on this issue and how reflectively that stance has been developed. To simply negate a patient's view of her embodiment as "foolish" or "unrealistic" is to violate a fundamental feature of that individual's dignity.

    Each person has a set of beliefs which is peculiar to that person. And even if beliefs are shared among individuals they often vary in intensity and priorities. One may have a strong belief in a divine source guiding her life and destiny. Another may share a similar belief but be eager to take a hand in directing her destiny as well. Some may have certain beliefs about the ability of traditional medicine to act in a healing way while the beliefs of others may point to an alternative direction in the healing arts. Patients have many different beliefs about the benefits of medicine as they approach the ends of their lives.

    In all of these situations and belief contexts there will be a large variety of alternative treatments possible for selection. For this reason consent to and refusal of treatments are essential and they must be based not only on relevant information but also on placing that information within the proper belief context. To minimize or disregard a belief system as "inappropriate" violates the patient's dignity because it assaults one of the central forces which allows individuals to manage their lives. In a sense, an individual's beliefs are the gyroscope which guides all the other facets of personal dignity.

    The attitudes and feelings which we hold give texture to our lives in a way which no other facet of dignity can provide. The complexity which they give to personal dignity is immeasurable, as is their importance. To truly understand an individual, and ourselves, we must understand the posture which we take toward the richness of experience as well as the emotive responses which those experiences elicit. These dimensions admit of incalculable levels of intensity. They may make the difference between a cooperative spirit between patients and caregivers and antagonisms which jeopardize any healing power which may be possible. They may make the difference between resisting a disease or surrendering to it. They may cloud our abilities to receive information to make wise decisions or they may open us to coming to know precisely what we need to know. They may orient us, disorient us, or a range of possibilities between those poles, in our attempts to come to terms with our finitude.

    As with other facets of dignity, our attitudes and feelings cannot be minimized or disregarded without violating our dignity itself. Caregivers must not only attempt to be aware of the attitudes and feelings of their patients but they must be aware of their own as well. Attitudes and feelings are seldom communicated in articulated ways. Rather, they are communicated subtly. But they are communicated nonetheless. To be open to this communication is a particular challenge to the healthcare professional. Sensitivity in this area is not easy to develop but it may make the difference between following the patient's wishes and doing what the caregiver merely thinks the patient wants.⁽¹³⁾ The former respects patient dignity, the latter often violates it.

    Patients come to the clinical setting with different levels of cognitive content, i.e., with different knowledge about themselves, the world in which they live, and the healthcare issues which they are facing. Our culture has moved far beyond the stage when we could presume that individuals have similar levels of education and intelligence. Similarly, it is unrealistic to assume that patients are totally ignorant of disease processes, symptoms, and therapeutic possibilities. Moreover, many patients frequently desire to overcome any ignorance which they may have.

    The dynamics of informed consent have been designed to address this facet of patient dignity and others as well. Different patients will have different levels of curiosity about their healthcare conditions and different abilities to understand all that is at stake. If caregivers wish to respect the dignity of their patients they will be solicitous about the level of understanding which their patients wish to achieve.⁽¹⁴⁾ They will bring their patients to that level in language which the patients can comprehend and respect the knowledge which patients bring to the clinical setting. To ignore the cognitive content of the patient is to subvert the foundation of the patient's power to give consent to treatment or refuse it.

    Another important dimension of personal dignity is the accumulation of the choices and preferences upon which individuals have acted throughout their lives. Our lives are structured as a result of those choices. The choices which we have made and the narrative of our actions which have resulted from them give texture to our lives and a strong case can be made that the cumulative effect of those choices constitute our identity.⁽¹⁵⁾ Patients come to the clinical setting with a history of those choices. To deny the significance of those past choices as they condition the present choices which must be made would surely constitute an assault on the patient's dignity.

    The making of choices in healthcare is another dimension of patient dignity which is protected by informed consent. Just as the "informed" side singles out cognitive content for special attention, so also the "consent" side singles out the process of choosing. The ability to make choices and assuming the accompanying responsibilities for the choices which are made constitute distinctively human features which demand recognition.

    The expectations and hopes which individuals have about their lives constitute other areas of personal dignity which are peculiar to each person. Some will have expectations which far exceed reality while others will adjust their expectations to fit within the context which they face. In respecting patients' dignity it will be necessary to give them the opportunity to adjust their expectations in light of the healthcare conditions which they have encountered. This will be particularly important if their expectations far exceed the reasonable limits of healthcare interventions. It sometimes happens that patients will have expectations which are at variance with their caregivers. Some patients are ready to surrender to a disease process long before their caregivers. It is important for caregivers to realize that the imposition of their own agenda of expectations on patients may very well constitute a violation of the patient's dignity because the patient's dignity has been minimized and put in second place after the caregiver's.

    Maintaining hope in a therapeutic relationship is essential for the curative process. However, patients cannot always hope for a cure. The reality of this fact must be made clear to patients when it is appropriate. When this becomes apparent in the disease process, patients can then adjust their hopes according to their own values and the inevitable outcome of the disease process. One need not always have hope for cure in order to have hope. Even in the process of dying one can have hope, e.g., hope of being free from pain, hope of not being isolated or abandoned, etc. The direction and intensity of these hopes will be individualized from patient to patient.

    One of the most difficult problems which caregivers face in their clinical interactions with patients is the tolerance which patients have for taking risks. We saw in the previous section that it is part of our fundamental humanity to make moral decisions about matters with uncertain outcomes. We continually take risks and generally attempt to minimize them.⁽¹⁶⁾ But each person has a different tolerance level for taking risks. We often find this reflected in ordinary conversation where it is not unusual to hear comments like: "I would never think of doing something like that" or "It's too risky for me."

    Healthcare is an area that expends great efforts to minimize risks. Caregivers are trained in a tradition which urges them to be cautious and to pursue the "safest" course for patients whenever possible. Great risks are undertaken only when there is a concomitant reason for taking them and when the "safer" course is unreliable or ineffective.

    However, patients may be willing to take risks where caregivers are not, or vice versa. Patients may wish to pursue experimental treatments or alternative therapies when the caregivers may think such courses of action are foolish. On the other hand, some patients may wish to yield to a disease process and the natural course of events when the caregiver may think that more aggressive efforts may improve the condition of the patient.

    This facet of patient dignity is another which is highly complex and one which must be regarded with great sensitivity and, often, deference. When patients refuse treatment or particularly when they complete an advance directive they are assuming risks as a result of their moral decisions. Because of the risks involved, treatment refusals or advance directives are not decisions to be taken lightly. Nor are they decisions to be ignored. Instead, the weighing of risks must be carefully undertaken. A discussion of and openness to the risks involved must be an integral part of the clinical relationship.⁽¹⁷⁾

    The nature of the relationships which individuals have is an area of personal dignity which has received dramatic attention since the onset of the AIDS crisis. The choices which individuals make of sexual partners are intensely personal ones. But even beyond this feature, are the levels of trust and affection which unite members of families whether they be homosexual or heterosexual families. The variety of the forms which families take is a challenge to any caregiver. And yet the caregivers can never hope to mould the features of the patient's relationships into one which is completely pleasing to the caregiver.

    Respecting the dignity of patients means that one respects the network of relationships in which they are involved. This will require caregivers to respect and utilize the patient's relationships when difficult decisions are made about treatment refusals. It will also call for encouraging patients to discuss the details of the wishes expressed in their advance directives with those who are intimate partners of those relationships. Finally, the respect for relationships will require a special respect for the one who is appointed as the attorney-in-fact in a durable power of attorney. Because of the level of trust which exists between the patient and this appointee, it will be necessary for caregivers to extend the same measure of respect to the attorney-in-fact which is extended to the patient. To disregard the wishes of the patient as expressed by the attorney-in-fact is to violate the fundamental dignity of the patient.

    One of the features of human dignity upon which we seldom reflect is that of the activities that are a part of the individual's life. Many individuals invest a great deal of energy in the activities which are central to their lives. The loss of the voice to a performer, the loss of physical dexterity to the athlete, the loss of memory to the educator all constitute serious threats to their personal dignity as they have fashioned it. The compromise, or loss, of mentation is a threat to the dignity of many individuals, a threat which is often considered to be worse than death itself.

    We invest so much of ourselves in some of our activities that we can hardly imagine ourselves not being able to participate in those activities; our personal identity is so bound to those activities. When the crisis of disease or injury intrudes into our lives, compromising those activities, we may well choose not to maintain our lives in such a compromised condition. Fir example, the quadrapalegic is frequently faced with such a difficult choice. Often, patients in a severely compromised condition would prefer to forego further treatments which would maintain them in this state. But they are coerced into accepting or receiving the treatments because of the desires of family members or caregivers.⁽¹⁸⁾

    One particular application of this facet of personal dignity applies to the issue of advance directives. Some living will legislation carries the stipulation that patients must be terminally ill before the advance directive can be carried out.⁽¹⁹⁾ This stipulation may very well strike at the heart of personal dignity by restricting the exercise of the patient's power of choice. Individuals who anticipate the loss of mentation ought to be able to express such anticipation in their advance directives regardless of the form the advance directives take.

    In this context of examining personal dignity it seems appropriate that patients should be able to refuse treatments which will keep them in the state of seriously compromised mentation. These treatments might be antibiotics for infections, tube feedings if they refuse food by mouth, diabetic medications, etc. For such individuals, their dignity lies in their power to choose their lifestyle and in their ability to engage in acts of mentation. To deny them the right to refuse treatment with the loss of mentation would be to violate their dignity on two fronts, namely, the loss of mentation itself and the restriction of choice in the face of this loss.

    It is an axiom in healthcare that patients respond differently to disease and injury as well as to their symptoms and therapies. Some patients will react with fear and apprehension. Some will respond with interest and curiosity. Others with acceptance and resignation. All of these responses make up yet another facet of their personal dignity. Responses in these areas will set the stage for treatment selection or refusals and for an interest (or its lack) in advance directives. The responses of patients can neither be ignored or minimized. Instead, they should be encouraged to the point of articulating them in some coherent and exploratory fashion as yet another way to express their dignity.

    Although there are many more facets of personal dignity which could be explored, no list would be complete without some discussion of aging. Everyone approaches the prospect and the reality of aging differently. Some approach aging with fear, others with complacency and resignation. But regardless of one's attitudes aging is a time of diminishing capabilities and function. It is a time when one's body begins to breakdown in significant ways, and an increasing number of healthcare interventions are necessary to maintain some degree of homeostasis. And, of course, the other end of aging is death.

    What was said about the aspects of human finitude in the earlier section need not be repeated here. But what is important to mention is that the extent to which one prepares for declining function and disease in the aging process, is very much a part of our dignity as human beings. We can be sure that, in the process of aging, there is increased likelihood for a decline in mental functioning. We can also be sure that, with increasing decline in physical functioning there will be a greater need for healthcare interventions. And, finally, we can be sure that often interventions in an aging organism might very well not return the organism to a previous level of functioning or a minimally decent quality of life.

    The Patient Self-Determination Act affords the opportunity to approach the issue of patient dignity in a comprehensive manner. If taken seriously the law can encourage a detailed exploration of the components of dignity. Patients can reflect upon them and caregivers can turn their attention to them. In the dialogue which ensues between patients and caregivers dignity can be both respected and enhanced through a better understanding of patients' beliefs, attitudes, feelings, preferences, hopes, expectations, tolerance of risks etc. The dignity of the patient lays the foundation for any decision to select or refuse treatment or draft an advance directive. A clear understanding of one's dignity gives direction to the choices one might make.

    Of particular interest is the place of advance directives as a manifestation of dignity in an aging population which might suddenly become critically ill. It is not sufficient to simply have an individual sign an advance directive. It is essential that conversations be conducted with such individuals and specific preferences be identified so that the dignity of the critically ill elderly person will be preserved.⁽²⁰⁾ It so often happens that a situation develops in which the preservation of the dignity of the elderly and the critically ill is left to the decisions of others. The direction which those decisions often take is to make every effort to extend the life of the patient. In point of fact, that approach may be the one which violates the dignity of the patient most forcefully. The only way to avoid this extreme is to enter into carefully crafted conversations with the aging population and those who are approaching that time of their lives.⁽²¹⁾ These conversations should explore the prospects of aging, health, and decline. They should be tailored to the enhancement of the dignity of the person by allowing them to articulate their wishes by exploring those elements which are most central to their dignity.

    The Patient Self-Determination Act provides the perfect opportunity to begin such conversations and to carry them to conclusion and implementation. The law demonstrates that there is a genuine societal attempt to promote dignity at a time in one's life when her dignity is so often compromised as are so many other aspects of her life. The advance directive is, perhaps, one of the most effective tools in addressing the healthcare needs of the elderly. It can enhance the quality of their lives by reducing the fear of what will befall them if they become critically ill. And it can enhance the quality of their dying by guaranteeing that no futile or unwanted interventions will extend their dying beyond the time they themselves specify.

    In this lengthy exploration of personal dignity, the emphasis has been placed on the dignity of the patient because the Patient Self-Determination Act primarily addresses the interests of patients. However, it must be noted that caregivers and the members of the patient's family are also repositories of dignity as well. They bear all the same features of dignity as patients. Frequently these features will come into conflict. The wishes of the patient are not always the wishes of the family, and often the wishes of patients and families are not the wishes of the caregivers. The foundations of personal dignity underlying those wishes will often not coalesce. The resolution of such conflicts is not always easy and it may be that some compromises in one or the other facet of dignity will have to be made along the way.

    However, the Patient Self-Determination Act gives preference to preserving the dignity of patients when such conflicts occur. There are two reasons for this. The first reason lies in the vulnerability of the patient. Disease and injury make patients particularly vulnerable.⁽²²⁾ At the time when this vulnerability is so great it becomes important to compensate for it by strengthening the patient's position wherever one can. Respecting the dignity of the patient is a very powerful way of limiting patient vulnerability.

    The second reason for respecting the patient's dignity above other's is that, in the final analysis, the patient is the one who must most directly bear the burden of the decisions which are made. It is the patient who will linger on in the dying process. It is the patient who will suffer the pain of the disease or injury. It is the patient who will suffer the insult of compromised functioning. It is the patient who will die the death. In respecting patient dignity the sacrifice to families is great and the challenge to the professionalism of caregivers is often extreme. But without meeting these challenges and accepting these sacrifices, the dignity of the patient stands in real jeopardy and its violation seldom enhances the quality of healthcare.

    The above analysis does not claim to be an exhaustive list of the facets of individual dignity. Many more features could be explored. But it does give a reasonable profile of the extraordinary complexity which is involved when imperatives are formulated about respecting personal or patient dignity.

    The process of understanding the dignity of individual patients, and respecting it, is further complicated by the fact that there is a time dimension to each of the facets. There may be a difference in the way patients manifest the various dimensions in the present as compared with their previous encounters with healthcare. Furthermore, there is no guarantee that the present priorities of the facets of their dignity will manifest the same pattern in the future. It is for this reason that advance directives involve some measure of risk. Patients anticipate that their dignity will call for actions in the future which seem to be appropriate in the present. There is only one way to manage this time dimension of personal dignity. It requires that there be on-going conversations between patients and caregivers which will monitor changes in the way patients view themselves and the demands of their personal dignity.

    The Patient Self-Determination Act will not adequately deal with the issues of patient dignity if caregivers and patients rely only on pieces of paper to fulfill the spirit of the law. A signature on a consent form, or on a refusal of treatment form, does little to reveal the personal issues with which an individual has dealt in reaching the conclusion documented by the form. The signature does not even guarantee that the patient has addressed the issues at all with any measure of reflection. Similarly, a signature on an advance directive may not demonstrate the facets of personal dignity which lie behind it. Without the interpersonal exchange through conversations between caregivers and patients, the Patient Self-Determination Act will remain a fundamentally sterile exercise, and any respect for patient dignity which results from it will be accidental at best.

1. Garrett TM et al. Health care ethics: principles and problems. (3rd edition.) Upper Saddle River, NJ: Prentice Hall, 1998, page 7.
2. A sample of these codes would include the Code of Ethics of the American Medical Association (item # 1), the American Nurses' Association Code for Nurses (item # 1), and The Patients' Bill of Right developed by the American Hospital Association (item # 12).
3. Because the Patient Self-Determination Act places such emphasis on informing patients that they have the right to consent to or refuse treatments, and because such decisions can only be made effectively against the backdrop of patients' values and many other elements which are intensely personal to them, the Patient Self-Determination Act invites us to explore and understand the range of those elements which comprise the dignity of the patients who are making the decisions.
4. Immanuel Kant best articulated this approach to the issue of dignity with his basic moral principle that "persons are to be treated as ends and not merely as means." (Cf. Kant I. Critique of practical reason. New York: Bobbs-Merrill Company Inc., 1956, pages 114-115. Cf. also Kant I. Metaphysical foundations of morals. In Friedrich CJ (ed). The philosophy of kant. New York: Modern Library, 1949, page 176.)
5. National Conference of Catholic Bishops. Ethical and religious directives for catholic health care services. Washington, D.C.: National Conference of Catholic Bishops, 1995, page 5.
6. Catechism of the catholic church. Washington, D.C.: United States Catholic Conference, 1994, # 321.
7. Gould SJ. Ever since darwin: reflections in natural history. New York: W.W. Norton & Co., 1977 pages 113-114. Cf. also Teilhard de Chardin P. Human energy. Trans. by Cohen JM. New York: Harcourt, Brace, Jovanovich, Inc., 1969, page 115.
8. Sartre JP. Being and nothingness. Barnes HE (trans). New York: The Citadel Press, 1965, pages 529-532.
9. Fackenheim EL. Metaphysics and historicity. Milwaukee, WI: Marquette University Press, 1961, pages 28-34.
10. Crawford C. The buddhist response to health and disease in environmental perspective. In Fu CW, Wawrytho SA. Buddhist ethics and modern society. New York: Greenwood Press, 1991, pages 185-193.
11. Waters F. Book of the hopi. New York: Penguin Books, 1963, pages 7-11.
12. Engelhardt HT. Medicine and the concept of person. In Beauchamp TL, Walters L. Contemporary issues in bioethics. 2nd edition. 1982, page 95.
13. It is instructive to note that caregivers often misunderstand patients' attitudes toward healthcare interventions, presuming that patients would want an intervention when, in point of fact, they do not. Caregivers seem to be wrong as least as many times as they are right. (Cf. Seckler AB. Substituted judgment: how accurate are proxy predictions? Ann Intern Med 1991;115:92-98.) Thus, it is important for caregivers to explore the attitudes of patients about healthcare interventions. Moreover, the suggestion has been made that, when patients or surrogates demand "futile" therapies the proper response is to explore the patients' and/or surrogates' attitude and feelings which prompt the demand rather than automatically comply with their wishes. (Cf. Ruark JE et al. Initiating and withdrawing life support. N Engl J Med 1988;318:25-30.) This approach to communication with patients and surrogates underscores the importance of this facet of personal dignity.
14. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: the ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: U.S. Government Printing Office, 1982, pages 57-60.
15. MacIntyre, A. After virtue. Notre Dame, IN: University of Notre Dame Press, 1981, pages 202-204.
16. Fischhoff B. Acceptable risk. New York: Cambridge University Press, 1981, pages 2-7.
17. Allowing risk-taking choices is not only a matter of respecting one's moral integrity but it is a feature of our humanity which is protected by the law in the classical notion of "the right to be let alone." This right comes particularly into play when there are conflicts between patients and caregivers regarding appropriate risks. Justice Warren Burger put the matter very clearly when he wrote: "Nothing in [his] utterance suggests that Justice Brandeis thought an individual possessed these rights only as to sensible beliefs, valid thoughts, reasonable emotions, or well-founded sensations. I suggest he intended to include a great many foolish, unreasonable, and even absurd ideas which do not conform, such as refusing medical treatment even at great risk." (Application of President and Directors of Georgetown College, 331 F.2n 1010 (D.C. Cir.), (1964).
18. The four cases examined in chapter 2 are good examples of this phenomenon.
19. There may be more latitude accorded to an attorney-in-fact when appointed in a durable power of attorney for healthcare. (Cf. endnote 20 in this chapter.)
20. The need for these conversations and their implementation has been made clear for the inconsistency with which specific instructions from patients were followed in the SUPPORT study. (Cf. Teno JM et al. Do advance directives provide instructions that provide care. JAGS 1997;45:508-512.)
21. Walker RM. Living wills and resuscitation preferences in an elderly population. Arch Intern Med 1995;155:171-175.
22. Pellegrino E. Altruism, self-interest, and medical ethics. JAMA 1987;258:1939-40.